Health Promotion and Screening Winter 2014 Women’s Healthcare: Diagnosis and Management Molly Altman, MN, CNM, MPH

What is Health? Definition: WHO (1948) – “A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” AMA (2003) – “A state of physical and mental well-being” Can you think of other definitions of health? What about health promotion? Health promotion and disease prevention is now the focus rather than just diagnosis and treatment of disease. Healthy People 2020 as example for country-wide initiative towards health promotion

Prevention as a concept Primary prevention: services focused on preventing disease in susceptible populations Examples: health education and counseling, targeted immunizations, lifestyle modification strategies Secondary prevention: services focused on the early detection and prompt treatment of disease states Examples: laboratory screening tests, pap smears, screening mammograms Tertiary prevention: services which limit disability and promote rehabilitation while in disease states Examples: eye exams for those with diabetes, follow-up exams for recurrence of cancer

Counseling and education is KEY! Some examples: Dental health Diet and exercise Injury prevention (seatbelts, helmets) Household safety (poisons, guns) Recreational safety (reflective vests, PFDs) Fall prevention (railings, fixed carpets) Sexual behavior Tobacco use

Prevention as a concept Fits into EVERY patient visit Applies at all levels Individual Family Community System

Case #1 Marissa, a 19 year old female college student comes to the university health clinic with a complaint of vaginal itching and burning for the past 3 days. As you sit with her getting her history, she admits to having not seen a provider since she was in high school. She has had 3 sexual partners over the past 4 months, and has “tried” to use condoms but admits to sexual encounters in which she “doesn’t remember”. When you ask about birth control methods, she shrugs her shoulders and states that she doesn’t need it. What other information do you want to obtain from her?

Case #1 continued What are examples of primary prevention you could use in this example? What are examples of secondary prevention you could use? If Marissa’s age was 22 instead of 19, would you do anything differently?

Case #1 continued Areas for focus and concern: Immediate problem – vaginal itching and burning Primary prevention measures – counseling for risky sexual behaviors, safer sex, contraception, personal safety, violence screening, immunizations Any others? Secondary prevention measures – screening for STIs, pregnancy, vaginal infections

US Preventive Services Task Force Recommendations for Preventive Screening http://www.uspreventiveservicestaskforce.org

USPSTF: A & B Recommendations The Affordable Care Act has mandated that all USPSTF A & B recommendations are covered in full (100%) by every insurance carrier. Pertains to billable screening and counseling services Others are often covered, but depends on insurance company (USPSTF A and B Recommendations. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm)

USPSTF: A & B Recommendations Primary Care The USPSTF recommends for/that: screening for high blood pressure in adults age 18 years and older. screening women ages 20 and older for lipid disorders if they are at increased risk for coronary heart disease. screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up. clinicians screen women of childbearing age for intimate partner violence, such as domestic violence, and provide or refer women who screen positive to intervention services. This recommendation applies to women who do not have signs or symptoms of abuse. screening all adults for obesity. Clinicians should offer or refer patients with a body mass index of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions. clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. USPSTF A and B Recommendations. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm

USPSTF: A & B Recommendations Women’s Health Care The USPSTF recommends for/that: primary care providers screen women who have family members with breast, ovarian, tubal, or peritoneal cancer with one of several screening tools designed to identify a family history that may be associated with an increased risk for potentially harmful mutations in breast cancer susceptibility genes (BRCA1 or BRCA2). Women with positive screening results should receive genetic counseling and, if indicated after counseling, BRCA testing. screening for cervical cancer in women ages 21 to 65 years with cytology (Pap smear) every 3 years or, for women ages 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years. screening for chlamydial infection in all sexually active nonpregnant young women age 24 years and younger and for older nonpregnant women who are at increased risk. clinicians screen all sexually active women, including those who are pregnant, for gonorrhea infection if they are at increased risk for infection (that is, if they are young or have other individual or population risk factors). clinicians screen for HIV infection in adolescents and adults ages 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened. clinicians screen persons at increased risk for syphilis infection high-intensity behavioral counseling to prevent sexually transmitted infections (STIs) in all sexually active adolescents and for adults at increased risk for STIs.

USPSTF: A & B Recommendations Older Women’s Health Care The USPSTF recommends for/that: the use of aspirin for women ages 55 to 79 years when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage. screening mammography for women, with or without clinical breast examination, every 1 to 2 years for women age 40 years and older. screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods vary.   screening for osteoporosis in women age 65 years and older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors. USPSTF A and B Recommendations. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm

Other preventive screening/counseling recommendations Thyroid screening: insufficient evidence Skin cancer screening: insufficient evidence Vitamin D screening: recommendation in progress Ovarian cancer screening: recommendation against routine screening (D) Combined or estrogen-only hormone replacement therapy: recommendation against use Diabetes screening: insufficient evidence for normotensive adults, recommended if co-existing hypertension

Case #2 Susan is a 52 year old woman presenting to your clinic for a health maintenance exam. She saw on the TV a recommendation for women her age to get a colonoscopy and wanted to know more about it. She has been married to John for 32 years, monogamous, has two adult children, and she has not had a period for 2 years now. Her last visit to a provider was 6 years ago, when she was told she needed a mammogram and she couldn’t afford the out-of-pocket portion. She was scared to go back because of this. What other information would you like to know from Susan?

Case #2 continued What primary prevention strategies could you use during this visit? What secondary prevention strategies would be appropriate? What could you tell her about her insurance coverage regarding the tests you may be recommending?

Case #2 continued Areas for focus and concern: Immediate problem – lack of preventive screening Primary prevention measures – diet and exercise counseling, ask about tobacco use, immunizations Any others? Secondary prevention measures – screening for hypertension, hyperlipidemia, diabetes (if elevated BP), intimate partner violence, mammogram, colonoscopy or signmoidoscopy, pap?

Resources to know… Healthy People 2020 http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx United States Preventive Services Task Force (USPSTF) and the Affordable Care Act http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm Centers for Disease Control and Prevention (CDC) Recommended Vaccine Schedule http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-schedule-easy- read.pdf U.S. Dept of Health and Human Services, Office on Women’s Health www.womenshealth.gov

Questions?